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目的通过医护一体化的病历管理方法提高运行病历的安全性,实现运行病历的规范化管理。方法 2014年4月成立科室病历管理小组,科室主任担任组长,病房护士长担任副组长;制定病历安全管理制度、规范和流程,制定缺陷管理条例;组织全科学习,知晓相关制度流程及管理方法;明确责任人;定期反馈病历安全管理的结果。将实施管理方法前(2014年1月-3月)及管理方法后(2014年4月-6月)病历归架率、病历车上锁率进行前后对比。结果实施前检查归架病历有11 890份次(96.95%),散放病历有374份次;实施后归架病历有11 870份次(99.66%),散放病历有40份次;实施前后的病历归架率差异有统计学意义(χ2=264.349,P<0.001)。实施前后分别检查病历车上锁情况181次,实施前病历车上锁次数为110次(60.77%),实施后为141次(77.90%);实施前后病历车上锁率差异有统计学意义(χ2=12.486,P<0.001)。结论运用医护一体化病历管理方法能够有效提高运行病历安全性。
Objective To improve the safety of medical records through the integration of medical record and medical records management, and to realize the standardized management of medical records. Methods In April 2014, a department medical records management team was set up. The director of the department served as team leader and the ward nurse served as the deputy team leader. The medical record safety management system, norms and procedures were formulated, and defect management regulations were formulated. Organizational study and knowledge of the relevant system processes and Management methods; clear responsibility; regular feedback on the results of medical records safety management. Before and after the implementation of management methods (January-March 2014) and management methods (April-June 2014), the rates of medical records and the locking rates of medical records were compared. Results Before the implementation, there were 11 890 medical records (96.95%) and 374 medical records were released. After the implementation of the medical records, there were 11 870 medical records (99.66%) and 40 medical records distributed. Before and after implementation The difference was statistically significant (χ2 = 264.349, P <0.001). Before and after the implementation of the medical records were checked lock situation 181 times, before the implementation of medical records car lock for the 110 times (60.77%), after the implementation of 141 times (77.90%); before and after the implementation of the case car lock rate was statistically significant χ2 = 12.486, P <0.001). Conclusion The use of integrated medical records management method can effectively improve the safety of medical records.